Vitamin combination for providing protection during the chemotherapy and/or radio-therapy of malignant tumours

ABSTRACT

The invention relates to the use of a vitamin combination for improving the tolerance to chemotherapy and/or radiotherapy of malignant tumours.

The present invention concerns the use of an agent for improving thetolerability of the chemotherapy or/and radiation therapy of malignanttumours.

The occurrence of malignant tumours has steadily increased in the last20 years. Studies on patients with stomach cancer in various stages hasshown that a surgical removal of the malignant tumour is expedient inpatients with stomach cancer at an early stage but that surgicaltreatment alone is ineffective when the cancer has reached a moreadvanced stage. Local recurrences and distant metastases occur in 20 to30% of such patients in the first year after the operation and thepercentage is already 40% within the second year of monitoring. Theaverage 5 year survival rate of patients with colon cancer that had beentreated surgically is about 50%. Most of the monitored patients hadlocal recurrences and distant metastases. It turned out that antitumourtherapies such as chemotherapy or polychemotherapy or/and radiationtherapy are necessary in addition to surgical treatment.

In radiation therapy ionizing radiation is used with the aim of damagingthe tumour tissue. Ionizing radiation (e.g. gamma or X-ray radiation)can, however, also damage healthy tissue by generating radicals. Severeradiation complications usually occur at effective radiation doses andhence radiation therapy is normally carried out at considerably lowerdoses than would be required for the therapy to have an optimal effect.Radiation dermatitis, pulmonary fibrosis, damage to the mucous membranesin the gastrointestinal tract, increased pain and immunodepression forexample occur as radiation complications. Since the radiation alsoattacks healthy tissue, the success of the radiation therapy isconsiderably reduced which results in a reduced life expectancy of theaffected patients. Studies have shown for example that in patients withtumours at an advanced stage, doses of 60 Gy are necessary to have agood effect. However, such high doses are unacceptable withoutprotecting the organism due to the considerable side-effects.Information on the results of radiation therapies are given inJarmonenco (“Radiobiologie: Menschen und Tiere”). The following Table 1which is taken from this citation shows the tolerance dose for ionizingradiation for vital organs. TABLE 1 max. maximal SFD isoequivalencytolerance dose organ (Gy) FTD (Gy) (Gy) skin 7.2 119 72 50-70 spinalcord 3.3 35.5 21 50-57 left lobule of 7.1 115.6 70 30-50 the liver leftkidney 6.7 107 64 13-25 pancreas: head 6.9 111 67 — body 5.4 76 46 30-100 tail 2.5 23 14 — small intestine 5.4 76 46 35-45 maximum singlefocal Absorbed dose for the organs stated in the table dose (SFD): aftereach radiation treatment (5 treatments) with an SFD of 7 Gy. factor-timedose (FTD): In order to recalculate the damaging effect in the tissueafter irradiation with higher fractions (7 Gy) compared to the standardmethods (SFD = 2 Gy). max. isoequivalency: Total absorbed dose forvarious organs after 5 radiation treatments (calculated according tospecial radiological tables FTD). tolerance dose: Maximum toleratedradiation dosage for various organs without radiation protective agents.

An oxidation process that can be stimulated by irradiation is forexample liquid peroxidation in which free radicals lead to adecomposition of lipids. Lipid peroxidation products are formed in thisprocess such as malonic dialdehyde (MDA) and 4-hydroxy-2-trans-hexenal.Lipid peroxidation products are usually mutagenic substances that candamage the organism. The oxidation in the body that is induced byirradiation can result in the destruction of healthy tissue, DNA andcell membranes.

Previously agents such as mexamine and cysteamine hydrochloride wereused to protect healthy tissue during radiation therapy. The radicaltrapping properties of cysteamine (2-aminoethanethiol) have led to itsuse to treat radiation damage. However, these conventional radiationprotective agents have a high toxicity which results in considerableside-effects. The doses of radiation protective agents that have to beadministered to carry out an effective radiation therapy would beunacceptable for health reasons. Thus their range of applications andduration of their application is extremely limited.

Cell poisons are administered in chemotherapy and polychemotherapy whichare intended to specifically interfere with the growth of tumour tissue.5-Fluorouracil (5-Fu), cis-platinum and doxorubicin are traditionallyused as cytostatic agents. However, these agents have a low selectivityfor the tumour tissue and thus damage healthy tissue to a considerableextent. The cytostatic agents that are generally used can initiate lipidperoxidation due to the occurrence of free radicals in the organism.Hence the side-effects of chemotherapy that occur limit the dose ofthese agents that can be used and thus the effectiveness of theantitumour therapy.

As is the case for single therapies, damage to healthy regions of theorganism also occurs in the case of a combined radiation/chemotherapy.Even when tumour patients are only surgically treated, the alreadyweakened organism of the patients is subjected to additional stress as aresult of which oxidation processes can for example be stimulated in thebody.

Hence a major problem in treating malignant tumours by surgicalinterventions or/and chemo- or/and radiation therapy is that thesetreatments are an additional burden for the patient. Healthy parts ofthe organism are also damaged since the commonly used cytostatic agentsare unselective and the radiation can have an effect on the entireorganism.

The object of the present invention was to improve the tolerability ofsurgical interventions for malignant tumours and the chemotherapy or/andradiation therapy of malignant tumours.

This object is surprisingly achieved by using a certain combination ofascorbic acid, tocopherol and retinol containing ascorbic acid in a freeform and tocopherol and retinol in a free form or/and in the form ofpharmaceutically acceptable esters thereof and in a mass ratio relativeto one another of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as an acetate and retinol as an acetate.

Furthermore the present invention provides a process for producing anagent which improves the tolerability of the chemotherapy or/andradiation therapy of malignant tumours and is characterized in that acombination of ascorbic acid, tocopherol and retinol in which ascorbicacid is present in a free form and tocopherol and retinol are present ina free form or/and in the form of pharmaceutically acceptable estersthereof and are formulated as an active ingredient in a mass ratiorelative to one another of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbicacid, α-tocopherol as an acetate and retinol as an acetate.

In addition the present invention encompasses a method for improving thetolerability of the chemotherapy or/and radiation therapy of malignanttumours which is characterized in that an agent is administered whichcontains a combination of ascorbic acid, tocopherol and retinol in whichascorbic acid is present in a free form and tocopherol and retinol arepresent in a free form or/and in the form of pharmaceutically acceptableesters thereof and they are present in a mass ratio relative to oneanother of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as an acetate and retinol as an acetate.

Furthermore the invention concerns a combination of ascorbic acid,tocopherol and retinol containing ascorbic acid in a free form andtocopherol and retinol in a free form or/and in the form ofpharmaceutically acceptable esters thereof, in a mass ratio relative toone another of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as an acetate and retinal as an acetate for use as an agentfor improving the tolerability of the chemotherapy or/and radiationtherapy of malignant tumours.

The agent contains ascorbic acid, tocopherol and retinol in a mass ratiorelative to one another of 1.5-2.5:0.3-0.8:0.028-0.033, preferably of1.6-2.3:0.4-0.68:0.029-0.032, more preferably at1.8-2.1:0.5-0.65:0.030-0.032, particularly preferably of 2:0.6:0.033based on ascorbic acid, α-tocopherol as an acetate and retinol as anacetate.

The minimum dose of ascorbic acid, tocopherol and retinol is generally150 mg/day, 50 mg/day and 3 mg/day, respectively, based on ascorbicacid, α-tocopherol as an acetate and retinol as an acetate. Preferably1.5 g/day, 300 mg/day and 28 mg/day, respectively, are administered.While maintaining the inventive ratio of the vitamins relative to oneanother, the dose can be increased but the upper limits of the dose aregenerally 2.5 g/day, 800 mg/day and 33 mg/day, respectively, based onascorbic acid, α-tocopherol as an acetate and retinol as an acetate.

Furthermore, according to the present invention it is possible to addβ-carotene to the vitamin combination according to the invention as aresult of which the amount of retinol used can be reduced. This may beadvantageous in order to increase the long-term tolerability of thevitamin combination according to the invention in the patient.

Hence another aspect of the present invention is the use of acombination of ascorbic acid, tocopherol, retinol and β-carotenecontaining ascorbic acid in a free form and tocopherol and retinol in afree form or/and in the form of pharmaceutically acceptable estersthereof and β-carotene in a free form, and in a mass ratio relative toone another of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as an acetate and retinol as an acetate together withβ-carotene as an agent for improving the tolerability of thechemotherapy or/and radiation therapy of malignant tumours.

Yet a further aspect of the present invention is a combination ofascorbic acid, tocopherol, retinol and β-carotene containing ascorbicacid in a free form and tocopherol and retinol in a free form or/and inthe form of pharmaceutically acceptable esters thereof and β-carotene ina free form and in a mass ratio relative to one another of1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid, α-tocopherol as anacetate and retinol as an acetate together with β-carotene for use as anagent to improve the tolerability of the chemotherapy or/and radiationtherapy of malignant tumours.

According to the invention the total amount of retinol and β-carotene ispreferably composed of ⅓ retinol and ⅔ β-carotene where the inventivemass fraction of retinol in the vitamin combination in this aspect ofthe invention is adhered to the sum of the retinol and β-carotenefractions. The daily dose of β-carotene administered with the vitamincombination according to the invention is preferably 10 to 25 mg, morepreferably 15 to 20 mg, particularly preferably 16 to 19 mg. Theadministered doses of ascorbic acid, tocopherol and retinol arepreferably in the ranges defined above.

Ascorbic acid (vitamin C) is a water-soluble vitamin which is containedespecially in fresh fruits and vegetables such as rose hip, oranges,lemons and peppers. A vitamin C deficiency (hypovitaminosis C) causesscurvy (bleeding of the skin and gums even to the extent of teethfalling out), susceptibility to infection and growth disorders inchildren. Ascorbic acid is for example used as an antioxidant in foodswhere the antioxidant effect is mainly due to the fact that ascorbicacid can act as a radical trap.

Tocopherols (vitamin E) are fat-soluble vitamins which can for examplebe stored in liver and fat tissue. Of the various tocopherols such as α-β-, γ- and δ-tocopherol, α-tocopherol (including its esters) is usuallyreferred to as the actual vitamin E. Vitamin E has an effect onarachidonic acid metabolism (inhibition of thromboxane biosynthesis) andhas a anti-inflammatory effect. Vitamin E appears to mainly act as anantioxidant for unsaturated fatty acids, vitamin A and carotenes byscavenging hyperoxides and peroxides. Increased lipid peroxidation canoccur in vitamin E deficiency and muscle weakness and neurodegenerativechanges may be found.

Retinol (vitamin A) and esters thereof are also fat-soluble and play animportant role in the synthesis of visual purple (rhodopsin) in theretina. Hence a deficiency in this vitamin can lead to damage to theconjunctiva and corneal membrane of the eyes. Furthermore, vitamin Adeficiency can trigger growth disorders and an increased susceptibilityto disease. Vitamin A has antioxidant properties, but an excessiveingestion of vitamin A can result in disease symptoms such as headacheand nausea and also to hair loss, swelling of the bones etc.

β-Carotene is the actual provitamin A and is the most important of thecarotenes that belong to the carotinoid group. It occurs in carrots andother vegetables and is used among others as an antioxidant and dye.

The vitamin combination according to the invention can additionallyinclude common pharmaceutical additives such as binders, flavourings,dyes or/and sweeteners.

In the vitamin combination L-(+)-ascorbic acid (vitamin C) can be usedin a free form, tocopherol and retinol can be used in a free form andalso in the form of their pharmaceutically acceptable esters. β-Caroteneis optionally used in a free form. Tocopherol or/and retinol arepreferably used in the form of their pharmaceutically acceptable esterse.g. as acetic acid and succinic acid esters; the corresponding acetatesare particularly preferably used.

Tocopherol (vitamin E) can be present in the vitamin combination as α-,β-, γ- or/and δ-tocopherol where preferably α- or/and γ-tocopherol andparticularly preferably α-tocopherol is used.

The use of the vitamin C, E, A combination according to the inventionfor antitumour treatment such as in chemotherapy or/and radiationtherapy can improve the tolerability and thus the effectiveness of suchtreatments.

It surprisingly turned out that the ratio of the vitamins relative toone another is crucial for the effect of the combination. It was alsofound that the daily dose of the respective vitamins (and optionallyprovitamins) should advantageously be in a certain range (see above). Inthis connection a so-called no-effect-level was determined below whichefficacy was in general no longer observed. The values for vitamins C, Eand A in the vitamin combination according to the invention are about150 mg/day, 50 mg/day and 3 mg/day, respectively, for this (see above).

The vitamins should be taken simultaneously, partially simultaneously orone after the other with a time delay that is not all that great. Thevitamins can be administered or taken as tablets, capsules, powder or inan otherwise common form of administration at the appropriate dosage.One variant of this is to use a tablet or capsule which containsascorbic acid, tocopherol and retinol in the appropriate mass ratiowhere the core of the tablet or capsule contains the fat-solublevitamins E and A and this core is surrounded by a layer which containsthe water-soluble vitamin C. The vitamin agent can be taken oradministered orally or/and parenterally.

Furthermore, the invention envisages an administration by means ofinjection, in particular intramuscularly, subcutaneously or/andintravenously. In a preferred embodiment the vitamin combinationaccording to the invention is administered intramuscularly which may beparticularly advantageous compared to oral administration in patientswho can (temporarily) only be fed parenterally. In this connection it isalso preferable to administer vitamins E and A (optionally plusprovitamin A) intramuscularly but to preferably administer thewater-soluble vitamin C subcutaneously or intravenously.

In order to protect healthy tissue and to increase the effectiveness ofthe corresponding antitumour therapy, the vitamin combination can,according to the invention, be administered before, during or/and aftersuch a therapy.

Use of the agent according to the invention results in a selectiveprotection of healthy tissue which does not impair treatment of themalignant tumour. In contrast an isolated administration of theindividual vitamin components contained in the vitamin combination usedaccording to the invention does not result in a selective protection inantitumour therapies. For example it was shown based on animalexperiments that an isolated administration of vitamin E results in anaccumulation of this vitamin in the tumour since the tumour is a vitaminE trap. FIG. 1 compares the tocopherol contents in certain organs ofrats with sarcoma 45.

Accumulation of the antioxidant vitamin E in the tumour of ratsincreases the resistance, i.e. e.g. the radiation resistance, of thetumour. However, the organs that are not affected by the tumour havesuch a low vitamin E content compared to sarcoma 45 that they cannot beadequately protected from radiation or cytostatic agents.

In contrast the use of the special vitamin combination according to theinvention surprisingly selectively protects healthy tissue, i.e. thetoxic manifestations of radiation therapy and cytostatic agents arereduced. This considerably increases the antitumour efficacy ofcytostatic agents and irradiation which improves the results ofchemotherapy and irradiation in patients with malignant tumours.

Another advantage of the use of the vitamin combination according to theinvention is that, due to the reduced side-effects of antitumourtherapies, intensive irradiation and chemotherapies are possible whichwould not have been tolerated by the patients without the protectionaccording to the invention.

When chemotherapies or/and radiation therapies are carried out with theinventive protection from side-effects, substantially fewer localrecurrences and distant metastases occur in the affected patientscompared to patients which were not protected according to theinvention. The 5-year survival rate and the average life-span of suchpatients is surprisingly considerably increased by the inventiveadministration of the vitamin C, E, A combination. Hence as a result ofthe invention patients with malignant tumours can have a long-lastingprotection against the toxic effects of antitumour treatment.

In contrast to conventional radiation protective agents such asmexamine, the vitamin agent according to the invention is non-toxic. Inaddition to its enormous toxicity, mexamine has the disadvantage that itdoes not have a long lasting radiation-protective effect since it has ashort duration of action.

Yet another advantage of the use according to the invention of thevitamin combination is that the vitamin balance of the tumour patientsis regulated in a long lasting manner. Normally hypovitaminoses occur intumour patients even after the malignant tumour has been successfullysurgically removed. A normalization of the vitamin balance leads to astabilization of the immune system of the patient which in turnincreases the chances of recovery and thus the average life expectancy.

In addition the invention is characterized by the good availability ofthe active substances and their simple handling.

It is intended to further elucidate the invention by the figures andexamples.

DESCRIPTION OF THE FIGURES

FIG. 1: Comparison of tocopherol contents in certain organs of rats withsarcoma 45.

FIG. 2: MDA content in rats with sarcoma 45 compared to healthy animalswith and without administration of the combination according to theinvention.

FIG. 3: Weights of Kroker sarcomas in animals in various experimentalgroups:

-   -   Group I: administration of the vitamin combination according to        the invention before cyclophosphamide administration    -   Group II: only cyclosphosphamide administration    -   Group III: only the inventive vitamin combination    -   Group IV: placebo.

FIG. 4: Incidence of the formation of distant metastases in the variousgroups I-IV (see also table B4.2).

FIG. 5: Graphic representation of the average life-span of patients fromthe various groups (in months).

EXPERIMENTAL AND CLINICAL INVESTIGATIONS

A. Experimental Investigations

1. Dependency of Efficacy on the Dose

The efficacy of the combination of vitamin C, E and A depends on thedose. Experiments on this were carried out on three-month old white maleand female rats weighing 150 to 180 g which carried a transplantedsarcoma 45 at the stage of intensive tumour proliferation. The vitamincombination according to the invention was administered to them (groupIa) within 4 to 5 days before their decapitation. Group Ib consisted ofcomparable rats with transplanted sarcoma 45 which were not administeredthe vitamin combination. Group Ic which consisted of healthy animalsserved as an additional comparison.

Another experimental group of rats (IIa) was administered thecombination of vitamins C, E and A like group Ia but the dosage wasreduced ten-fold. Groups Ib and IIc are again rats with sarcoma 45 orhealthy animals, respectively, to which the vitamin combination was notadministered.

The doses used are summarized in table A1.1 in mg per gram body weight.The vitamins were injected subcutaneously into the animals. TABLE A1.1α-tocopherol group ascorbic acid acetate retinol acetate Ia (sarcoma 45) 0.2-0.3 mg  0.08-0.09 mg  0.001-0.002 mg Ib (sarcoma 45) — — — Ic(healthy) — — — IIa (sarcoma 45) 0.02-0.03 mg 0.008-0.009 mg0.0001-0.002 mg IIb (sarcoma 45) — — — IIc (healthy) — — —

The animals were killed and the malonic dialdehyde (MDA) concentrationin the livers of the animals was examined. Malonic dialdehyde is aproduct of lipid peroxidation which is increased by tumourproliferation. The concentration of MDA in the liver of the examinedgroup indicates the extent of lipid peroxidation in each case.

FIG. 2 shows that the MDA concentration in rats with sarcoma 45 isconsiderably increased compared to healthy animals since there is anincrease in the occurrence of lipid peroxidation in these animals. Areduction of the MDA concentration, i.e. lipid peroxidation, caused bythe vitamin C, E, A combination is dose-dependent as shown in FIG. 2.The MDA concentration in the liver of rats of group Ia which wereadministered the vitamin C, E, A combination is considerably reducedcompared to sarcoma 45 rats that did not receive the special vitamincombination (group Ib) and almost as low as the MDA concentration ofhealthy animals (group Ic). In contrast, no antioxidative effect isachieved with a ten-fold reduced dose of the vitamin C, E, Acombination; the MDA concentration in the liver of the animals of groupIIa is even slightly increased compared to the value that was found inthe liver of sarcoma 45 rats which were not administered the vitamincombination (group IIb).

2. Protection by the Vitamin Combination in Irradiation

Three groups each comprising white raceless male mice weighing 18 to 20g were administered the vitamin combination according to the invention24 hours before the corresponding whole body irradiation with the gammaray device “Rokus” (cobalt-60). Vitamins A and E were administered tothe animals in an oily solution by means of an oesophageal tube, vitaminC was injected subcutaneously as an aqueous solution. The dose was (inmg per gram body weight) 0.2-0.3 mg ascorbic acid, 0.08-0.09α-tocopherol acetate and 0.001-0.002 retinol acetate. The mice wereirradiated with 8 Gy (group Ia), 12 Gy (group Ib) and 14 Gy (group Ic)and the survival times of the animals was observed. As a comparisonthree groups of corresponding mice were irradiated but they were notadministered the vitamin combination (groups IIa, IIb and IIc).

The results of the irradiation are summarized in table A2.1. TABLE A2.1experimental % dead animals/days at irradiation dose group 8 Gy (a) 12Gy (b) 14 Gy (c) I (protection 16/30 50/9 50/8 according to theinvention) II (without 26/30 50/7 50/5 protection)

Table A2.1 shows that only 16% of the animals from group I were dead 30days after irradiation with a dose of 8 Gy whereas 26% of the animals ofgroup II which had not been administered the vitamin combination weredead at the same time. When the radiation dose was increased to 12 Gy,50% of the animals from group I were dead after 9 days and 50% of theanimals from group II were already dead after 7 days. The protectiveeffect of the vitamin combination is even more apparent when they wereirradiated with a dose of 14 Gy: 50% of the animals from group I stilllived after 8 days whereas half of the mice in group II were alreadydead after 5 days.

Accordingly the average life-span of the mice is considerably longerwhen they are administered the vitamin combination according to theinvention before the irradiation (table A2.2). TABLE A2.2 averagelife-span (days) at a radiation dose of experimental group 12 Gy (b) 14Gy (c) I (protection according to  9.0 ± 0.6*  7.9 ± 0.7** theinvention) II (without protection) 7.5 ± 0.5 5.5 ± 0.3*p < 0.05**p < 0.01

The mice survived 9 days on average at an irradiation dose of 12 Gy and7.9 days at 14 Gy when they were administered the vitamin combination.Animals from group II only survived for 7.5 and 5.5 days, respectively.

In order to compare the radiation protection according to the inventionwith the effect of conventional radiation protective agents whiteraceless male and female rats weighing from 150 to 180 g (age: 3 months)was subjected to whole body gamma irradiation at a dose of 11.4 Gy, theanimals being protected according to the invention by administering thevitamin combination at the above-mentioned dose 24 hours before theirradiation (group I). On the other hand another group of comparablerats was irradiated identically and the conventional radiationprotective preparation, mexamine was administered 24 hours beforeirradiation (group II). A third group of rats was irradiation withoutadministering a radiation protective agent (group III). The survivalrate and average life-span of rats from groups I, II and III aresummarized in table A2.3. TABLE A2.3 radiation dose 11.4 Gy experimentalgroup % dead animals/days average life-span (days) I (protection 50/88.4 ± 4*  according to the 100/16 invention) II (mexamine) 50/8 8.2 ±4*  100/13 III (without 50/5 5.4 ± 0.3 protection) 100/9 

Table A2.3 shows that considerable protection age radiation is achievedby the vitamin combination which results in an increase in the averagelife-span of the animals compared to unprotected irradiation orirradiation when mexamine is administered. The rats of group I have anaverage life-span of 8.4 days whereas animals of group II to whichmexamine was administered instead of the vitamin agent according to theinvention only lived on average 8.2 days after the irradiation. Theanimals lived 5.4 days on average (group III) when no radiationprotective agent was administered.

3. Protection by the Vitamin Combination in Chemotherapy

In order to assess the protective effect of the agent according to theinvention a group of white raceless rates weighing from 150 to 180 g(age: 3 months) was subcutaneously injected with the vitamin combination(for dose see 2) 24 hours before injection of 5-fluorouracil.5-Fluorouracil was administered at a dose of 1.8 mg per kg body weight(group I). Another group of rats did not receive the vitamin combinationwhile being treated correspondingly with 5-fluorouracil. The ability ofthe rats of these two groups to survive is compared in table A3.1. TABLEA3.1 5-fluorouracil (1.8 mg per kg body weight) ability to survive after8 days [%] experimental group (p < 0.002) I (protection according to theinvention) 82 ± 4.3% II (without protection) 61 ± 5.4%

Table A3.1 shows that after an observation period of 8 days, 82% of therats from group I but only 61% of the rats from group II (withoutprotection) had survived.

Hence the combination of vitamins C, E and A according to the inventionhad an outstanding protective effect in radiotherapy as well as inchemotherapy which was unexpected.

4. Protection by the Vitamin Combination in a CombinedRadiotherapy/Chemotherapy

A group of white raceless rats weighing from 150 to 180 g were firstlysubjected to a whole body irradiation (gamma ray device see under 2) ata dose of 8 Gy and then 5-fluorouracil (dose: 1.8 mg per kg body weightof the rat) was injected, the vitamin combination according to theinvention having been administered 24 hours before the irradiation inthe dosage stated in section 2 (group I). A second group of rats wastreated correspondingly but the animals were not administered thevitamin agent for protection (group II). The ability of the animals fromboth groups to survive is compared in table A4.1. TABLE A4.1 irradiation(8 Gy) + 5-fluoruracil (1.8 mg per kg body weight) ability to surviveexperimental group after 60 days [%] I (protection according to theinvention) 73 II (without protection) 41

Table A4.1 shows that even in the case of a combined chemo/radiotherapythe ability of the experimental animals to survive is vastly increasedby the vitamin C, E, A combination according to the invention. Thus 73%of the animals of group I still survived after 60 days whereas only 41%of the animals from group II still live after 60 days.

5. Selectivity of Vitamin C, E, A Combination

The radiation protection and the protection in chemotherapy of thevitamin combination according to the invention acts selectively onhealthy tissue and does not reduce the effect of the irradiation or ofthe cytostatic agent on the tumour. This selectivity was confirmedexperimentally by subjecting 4 rats of the above-mentioned species withWalker carcino-sarcoma to a single local irradiation in which only thetumour was irradiated at a dose of 20 Gy using the X-ray device RUM-11.The vitamin combination (dose see under 2.) was administeredsubcutaneously to two of these rats 24 hours before the irradiation. Thetumours of the irradiated donors were transplanted into healthy animalsdirectly after the irradiation. The recipient rats were not administeredthe vitamin agent. The tumour volumes of all examined animal groups weredetermined. The results show that there were no differences in thechanges of the tumour volumes. Hence the vitamin combination accordingto the invention had no protective effect against radiation with regardto the malignant tumour and can be used selectively to protect healthytissue from irradiation.

The selectivity of the agent according to the invention shown in theabove experiment was also confirmed by the following investigation:

White raceless mice weighing 20 to 25 g were implanted a Kroker sarcomaby conventional methods. The vitamin combination was administered to onegroup of the experimental animals 24 hours before they receivedcyclophosphamide (50 mg per kg body weight) (group I). For comparison agroup of mice was treated correspondingly, but without theadministration of the vitamin agent according to the invention (groupII). The animal group III was only administered the vitamin combination,the control group IV received a placebo. FIG. 3 compares the weight ofthe Kroker sarcomas of the animals of the various experimental groups.The vitamins were administered at a dose of 300 mg (vitamin C), 90 mg(vitamin E) and 20 mg (vitamin A) in each case per kg body weight.

The results are shown in FIG. 3. This shows that administration of thevitamin agent according to the invention does not protect the tumouragainst the cytostatic agent cyclophosphamide. This is apparent sincethe weight of the tumour is even less then when cyclophosphamide isadministered alone. The administration of the vitamin combinationaccording to the invention without the administration of a cytostaticagent also results in a reduction of the tumour weight compared to theadministration of a placebo.

B. Clinical Investigations

1. Characterization of the Patients

If not stated otherwise in the investigations, the ratio of men to womenin the respective treatment groups was practically equal and mostpatients were aged between 51 and 60 years. They had a body weight of50-100 kg.

2. Protection by the Vitamin Combination in Surgical Interventions

A group of patients with stomach cancer at an early stage wereadministered the vitamin C, E, A combination daily in the pre-operativephase for 7 days. Afterwards a surgical intervention was carried out andthe operated patients received the vitamin combination over a period of1.5 years (group I). Another group of comparable patients with stomachcancer at an early stage were operated in a corresponding manner but didnot receive the vitamin combination according to the invention (groupII).

The vitamin combination was administered orally at a dose of 2.0 gascorbic acid, 0.6 α-tocopherol acetate and 0.033 g retinol acetate.

The percentage survival rates of the patients of both groups after 1, 3and 5 years are shown in table B2.1. TABLE B2.1 patient group survivalrate (%) after (stage 1B) 1 year 3 years 5 years I (according to the96.6 ± 3.2 96.6 ± 3.2  90.9 ± 6.3* invention) II (only operation) 90.0 ±4.7 77.5 ± 6.6 70.0 ± 6.8*p < 0.025 compared to “only operation”

Table B2.1 shows that the survival rate compared to group II wasincreased by the administration of the C, E, A combination. After 1 year5% more patients from group I survive than patients from group II, after3 years the difference is already almost 20% and after 5 years it isover 20%.

Even in patients with stomach cancer at an advanced stage it waspossible to achieve astonishing survival rates in patients byadministering the vitamin combination according to the invention. Thisbecomes clear by comparing the percentage survival rates of the patientfrom group I which in addition to the operation had been administeredthe vitamin combination, with patients of group II who were onlyoperated on. Table B2.2 compares the survival rates after 1, 3 and 5years. TABLE B2.2 patient group survival rate (%) after (stage 3A) 1year 3 years 5 years I (according to the 85.7 ± 9.3 53.0 ± 14.0 53.0 ±14.0* invention) II (only operation) 84.7 ± 8.1 23.5 ± 6.2  11.7 ± 5.5 *p < 0.01 compared to “only operation”

Especially after 3 and 5 years the survival rate of patients from groupI is considerably increased compared to patients from group II; after 3years by 30%, after5 years by over 40%.

3. Protection by the Vitamin Combination in Chemotherapy

a)

A group I comprising patients with stomach cancer at stage IV (13patients) was intravenously administered 750 mg 5-fluorouracil dailyover 7 days. The pauses between the treatment cycles lasted 2 to 2.5months. These patients were administered the vitamin combination dailyduring the entire chemotherapy at a daily dose as stated in section 2. Acorresponding therapy with 5-fluorouracil was carried out with a groupII comprising patients at the same stage of the disease but withoutprotection by the vitamin agent.

The results of the control groups are taken from older literaturereferences.

Table B3.1 compares the survival rates of patients from groups I and II.TABLE B3.1 patient group survival rate (%) after (months) (stage IV) 3 69 12 18 22 44 I 5-Fu + invention) 100 77.0 53.9 46.2 30.8 30.8 23.1 II(only 5-Fu) 86.7 66.7 40.0 20.0 13.7 0 —

Table B3.1 shows that the survival rate of the patients with stomachcancer at stage IV is considerably increased when they are administeredthe vitamin combination during the chemotherapy. After 44 months 23.1%of the patients from group I are still alive. However, in group II nopatient survived up to the 22nd month. The survival rate of group Iafter 12 and 18 months is more than twice as high as that of group II.Hence the invention makes it possible to considerably increase theeffectiveness of chemotherapy and thus to ensure a longer survival ofthe patients.

The results of the group studies that were carried out show that thevitamin combination of the invention increases the antitumoureffectiveness of chemotherapies and considerably reduces their toxiceffect in the organism which improves the results of chemotherapy inpatients with stomach cancer at an advanced stage.

b)

A gastric carcinoma with initial skin metastasis was diagnosed in June2002 in a 74 year old female patient. Histologically it was a lessdifferentiated adeno-carcinoma matching the diffuse type according toLauren. A laparotomy was performed in August 2002, a peritonealcarcinosis was found but the finding was inoperable. Only biopsyspecimens were taken and a port system was implanted to administerchemotherapy. 5-Fu was continuously infused for 5 days in a total of 4cycles at 4 week intervals; the infused dose was 600 mg/m² (BS) bodysurface daily. This was followed by administration of 2 further cyclesat a dose of 750 mg/m² BS daily also for 5 days in each case. During theentire chemotherapy period, the vitamin complex was daily ingestedorally at the following dosage: vitamin C 2000 mg, vitamin E 600 mg andvitamin A 33 mg. The health of the patient was excellent during thisperiod neither decreases in leucocytes nor nausea, vomiting or mucositiswere observed. Imaging and blood chemistry control examinations showedthat the disease was absolutely stable under the combined treatment of5-FU and the vitamin combination according to the invention.

This treatment result shows that tolerance to chemotherapy isconsiderably increased by the vitamin combination according to theinvention and at the same time an improved therapeutic result can beobserved. Hence the present invention increases the chances of asuccessful treatment and thus improves the life expectancy of theaffected patients even in the case of severe cancer diseases.

4. Protection by the Vitamin Combination in Radiation Therapies

A major problem in the case of tumour patients is that these patientsusually suffer from a relapse in the post-operative phase and distantmetastases form. This occurs in 20 to 50% of the patients.

Patients with adeno-carcinoma at different stages were subjected tovarious treatments. Group I was exposed to radiotherapy at a dose of 20Gy in the pre-operative phase during which the patients wereadministered the vitamin combination according to the invention. Thiswas followed by the operation. Patients in group II were treated likepatients from group I but the radiation dose was 30 Gy. Patients fromgroup III were subjected to radiotherapy at a dose of 20 Gy before theoperation but they did not receive the vitamin combination. Group IVconsisted of patients which were only operated on.

The incidence of the formation of distant metastases in patients fromgroups I to IV is shown in table B4.1 versus their adeno-carcinomastructure after an observation period of 5 years. TABLE B4.1 adeno-group I group II group III group IV carcinoma A* A* A* A* stage B in % Bin % B in % B in % highly 0 0.0 0 0.0 2 33.3 6 18.8 differentiated 1{overscore (11)} 6 {overscore (32)} moderately 5 26.3 2 7.7 2 20.0 920.9 differentiated {overscore (19)} {overscore (26)} {overscore (10)}{overscore (43)} less 0 0.0 0 0.0 2 100 0 0.0 differentiated 3 4 2 9*A = number of patients with distant metastasesB = total number of patients

The formation of distant metastases of a highly differentiatedadeno-carcinoma was registered most frequently in group III: 33.3% ofthe patients in this group had distant metastases after an observationperiod of 5 years. This value is much higher than in the patients whichwere only subjected to an operation (group IV, 18.8%). Hence theradiation therapy had a damaging effect on the organism of the patientsunless the patients are administered the vitamin combination accordingto the invention for protection. Thus in patients of group I which werealso irradiated with 20 Gy but were protected by the vitamin combinationaccording to the invention, no distant metastases were found. Even whenthe radiation was increased to 30 Gy (group II), the patients had nodistant metastases. This effect is pronounced even in the case of lessdifferentiated adeno-carcinomas: all patients, i.e. 100% of group III,had distant metastases whereas distant metastases were observed neitherin group I nor in group II:

The protective effect of the vitamin agent in various radiationtherapies can even be observed in patients with colon cancer at variousstages. The incidence of distant metastases formation in patients withcolon cancer at various stages after an observation period of 5 years islisted in table B4.2. Patients of groups I to IV were subjected to theabove-mentioned therapies. TABLE B4.2 colon group I group II group IIIgroup IV cancer A* A* A* A* stage B in % B in % B in % B in % T3-4 NO-MO(II) 2 12.5 1 5.0 2 18.2 8 14.5 {overscore (16)} {overscore (20)}{overscore (11)} {overscore (55)} T2-4N1-MO (III) 2 28.6 1 8.3 4 50.0 847.1 7 {overscore (12)} 8 {overscore (17)}*A = number of patients with distant metastasesB = total number of patients

It is particularly apparent from table B4.2 that the vitamin combinationaccording to the invention increases the effectiveness of radiotherapysince the formation of distant metastases in patients of groups I and IIis reduced in comparison to patients that are only irradiated but notprotected according to the invention. Hence the radiation dose can beincreased without damaging healthy tissue of the patients. Patients ofgroup II which were irradiated with 30 Gy had only 5% (T3-4NO-MO (II))or 8.3% (T2-4N1-MO(III)) distant metastases whereas patients of groupIII who had only been irradiated with 20 Gy and had received no vitamincombination had 18.2% and 50.0% distant metastases, respectively.

These results are shown graphically in FIG. 4.

The overall incidence of distant metastasis formation depending on thetreatment method (groups I to IV) in patients with colon cancer after anobservation period of 5 years is shown in table B4.3. TABLE B4.3 group Igroup II group III group IV A* A* A* A B in % B in % B in % B in %number of 5 21.7 ± 1.9 2 4.9 ± 6 30.0 ± 4.5 16 18.4 ± 3.4 patients{overscore (23)} {overscore (41)} 1.5** {overscore (20)} 87 with distantmetastases formation*A = number of patients with distant metastasesB = total number of patients**p < 0.05 compared to group III

The formation of distant metastases occurs most frequently when patientsare irradiated (30%, group III). The vitamin combination according tothe invention can effectively protect healthy tissue from radiation.Only 21.7% of patients from group I which were irradiatedcorrespondingly under the inventive protection had distant metastases.The protective effect is particularly evident since this value is evensubstantially lower (4.9%) at a higher radiation dose (30 Gy, group II).

The use of the vitamin combination in pre-operative radiation therapyresults in a considerable reduction in the damage to healthy tissue. Theprotection according to the invention enables one to irradiate at higherdoses and thus to increase the effectiveness of therapies.

5. Protection by the Vitamin Combination in Combined Chemo/Radiotherapy

a)

Various patient groups were subjected to a combined chemo/radiotherapy.Patients with pancreatic cancer were treated surgically and thensubjected to a postoperative radiation therapy with subsequentpolychemotherapy.: group I: Radiation therapy with a total focal dose of35 Gy (single focal dose 7 Gy), 6 treatment cycles of polychemotherapy.group II: Radiation therapy as a secretion cure at radiation doses of 28Gy (single focal dose 4 Gy) plus 30 Gy (single focal dose 2 Gy), 6treatment cycles of polychemotherapy.

The polychemotherapy was carried out 15 to 20 days after the radiationtherapy. 300 mg/m² 5-fluorouracil was administered within the first 5days, 50 mg/m² doxorubicin was administered on the first day and 20mg/m² cis-platinum was administered during the first 5 days. Thecytostatic agents were administered intravenously. Pauses between thetreatment cycles of the polychemotherapy were 25 to 30 days. Allpatients of groups I and II were given the vitamin combination orally,once per day 24 hours before each treatment. A group of patients whichhad only been treated surgically served as a comparative group (groupIII). The data shown for the control group III are derived fromexperiments cited in older literature references.

The survival rates of patients from groups I to III are compared intable B5.1 TABLE B5.1 survival rate (%) after patient group 1 year 2years 3 years 5 years I 30.0  5.0 0  — II 45.0 15.0 10.0 5.0 III 0 — — —(control)

All patients in the control group III died within 12 months. Incontrast, combined chemo/radiotherapy together with the vitamin agentenable 5% of patients in group II to still live even after 5 years. Theaverage survival time of the patients of the three study groups is showngraphically in FIG. 5.

A comparison with a group which had been subjected to the samechemo/radiotherapy as groups I and II but without protection by thevitamin agent is ethically unacceptable but the values may be taken fromcontrol groups in the literature. They show that the toxicity of theadministered cytostatic agents and the radiation doses are so severethat the effectiveness of the treatments is limited. Only with theprotection of the vitamin combination according to the invention is itpossible to use such high doses which makes the therapies extremelysuccessful.

b)

An inflammatory mammary carcinoma of the left breast was diagnosed inApril 2002 in a 59 year old female patient. The histological findingswere a less differentiated invasive ductal mammary carcinoma withextensive lymphangiosis carcinomatosis of the skin. Hormone receptorstatus: oestrogen receptor 60%, progesterone receptor 70% positive,Her2-new: dako score 1-2, hence borderline. 6 cycles of chemotherapywith epirubicin/cyclophosphamide were administered intravenously on day1 at 3-week intervals as a neoadjuvant. 4 cycles the dose was 90 mg/m²BS epirubicin, 600 mg/m² BS cyclophosphamide. In the last 2 cycles theepirubicin dose was increased to 120 mg/m². From September to October2002 the left breast and the associated lymphatic drainage tracts wereirradiated at 50 Gy. During the irradiation the patient received thevitamin combination according to the invention daily which comprised2000 mg vitamin C, 600 mg vitamin E and 33 mg vitamin A. The radiationtherapy was tolerated very well and there was only a slight reddening ofthe irradiated skin areas; nausea and vomiting occurred just as littleas decreases in leukocytes. Punch specimens were taken from the leftbreast in December 2002 which gave no indication of malignancy.

This treatment report is a further impressive illustration of theimprovement of the tolerability of antitumour therapy due to theadministration of the vitamin combination according to the invention. Itshould be noted in particular that despite a very high irradiation doseof 50 Grey, none of the otherwise common side-effects such asdeterioration of the blood picture, nausea etc. were observed. Ingeneral such high radiation doses are associated with severeside-effects. Hence administration of the agent according to theinvention enables more effective chemo/radiotherapies to be used andthus improves the chances of recovering from malignant tumours. This isfor example illustrated by the above-mentioned case in which malignancywas no longer diagnosed in the punch specimens taken from the leftbreast of the patient after treatment according to the invention.

In summary it may be stated that administration of the vitamin C, E, Acombination according to the invention considerably increases thetolerability of radiation or/and chemotherapies since healthy tissue isselectively protected. Thus it is possible to also apply or administervery high radiation doses and very high doses of cytostatic agents.

1. Use of a combination of ascorbic acid, tocopherol and retinolcontaining ascorbic acid in a free form and tocopherol and retinol in afree form or/and in the form of pharmaceutically acceptable estersthereof in a mass ratio relative to one another of1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid, tocopherol as anacetate and retinol as an acetate, as an agent for improving thetolerability of the chemotherapy or/and radiation therapy of malignanttumours.
 2. Process for producing an agent which improves thetolerability of the chemotherapy or/and radiation therapy of malignanttumours, characterized in that, a combination of ascorbic acid,tocopherol and retinol is used in which ascorbic acid in a free form andtocopherol and retinol in a free form or/and in the form ofpharmaceutically acceptable esters thereof are formulated as an activeingredient in a mass ratio relative to one another of 1.5-2.5:0.30.8:0.028-0.033 based on ascorbic acid, a tocopherol as an acetate andretinol as an acetate.
 3. Method for improving the tolerability of thechemotherapy or/and radiation therapy of malignant tumours,characterized in that, an agent is administered which contains acombination of ascorbic acid, tocopherol and retinol in which ascorbicacid is present in a free form and tocopherol and retinol are present ina free form or/and m the form of pharmaceutically acceptable estersthereof and they are present in a mass ratio relative to one another of1.5-2.5:0.3-0.8:0.02-0.033 based on ascorbic acid, a-tocopherol as anacetate and retinol as an acetate.
 4. Use as claimed in claim 1,characterized in that, the agent contains ascorbic acid, tocopherol andretinol in a mass ratio relative to one another of1.8-2.1:0.5-0.65:0.030-0.032 based on ascorbic acid, α-tocopherol as anacetate and retinol as an acetate.
 5. Method as claimed in claim 2,characterized in that, the agent contains ascorbic acid, tocopherol andretinol in a mass ratio relative to one another of 1.8-2.1:0.50.65:0.030-0.032 based on ascorbic acid, α-tocopherol as an acetate andretinol as an acetate.
 6. Use as claimed in claim 1, characterized inthat, ascorbic acid, tocopherol and retinal are administered at aminimum dose of 1.50 mg/day, 50 mg/day and 3 mg/day and at a maximumdose of 2.5 g/day, 800 mg/day and 33 mg/day each based on ascorbic acid,α-tocopherol as an acetate and retinol as an acetate.
 7. Use as claimedin claim 6, characterized in that, the minimum dose of 1.5 g/day, 300mg/day and 28 mg/day based on ascorbic acid, α-tocopherol as an acetatea-ad retinal as an acetate is administered.
 8. Use as claimed in claim1, characterized in that, the agent contains α-tocopherol or/and retinalin the form of pharmaceutically acceptable esters thereof.
 9. Use asclaimed in claim 8, characterized in that, the agent containsα-tocophervl or/and retinol in the form of acetic acid or/and succinicacid esters thereof.
 10. Use as claimed in claim 8, characterized inthat, the agent contains α-tocopherol and retinol in the form of theiracetates.
 11. Use as claimed in claim 1, characterized in that, theagent additionally contains pharmaceutically acceptable binding agents,flavourings, dyes, sweeteners or/and other common pharmaceuticaladditives.
 12. Combination of ascorbic acid, tocopherol and retinol inwhich ascorbic acid is present in a free form and tocopherol and retinolare present in a free form or/and in the form of pharmaceuticallyacceptable esters thereof. and they are present in a mass ratio relativeto one another of 1.5-2.5;0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as art acetate and retinol as an acetate for use as anagent to improve the tolerability of the chemotherapy or/and radiationtherapy of malignant tumours.
 13. Use of a combination of ascorbic acid,tocopherol, retinol and β-carotene in which ascorbic acid is present ina free form and tocopherol and retinol are present in a free form or/andin the form of pharmaceutically acceptable esters thereof and β-caroteneis present in a free form and they are present in a mass ratio relativeto one another of 1.5-2.5:0.3-0.8:0.028-0.033 based on ascorbic acid,α-tocopherol as an acetate and retinol as an acetate together withβ-carotene, as art agent to improve the tolerability of the chemotherapyor/and radiation therapy of malignant tumours.
 14. Process for producingan agent which improves the tolerability of the chemotherapy or/andradiation therapy of malignant tumours, characterized in that, acombination of ascorbic acid, tocopherol, retinol and β-carotene is usedin which ascorbic acid in a free form and tocopherol and retinol in afree form or/and in the form of pharmaceutically acceptable estersthereof and β-carotene in a free form are formulated as an activeingredient in a mass ratio relative to one another ofX.52.5:0.3-0.8:0.028-0.033 based on ascorbic acid, a tocopherol as anacetate and retinol as an acetate together with β-carotene.
 15. Use asclaimed in claim 13, characterized in that, the total amount of retinoland β-carotene is composed of ⅓ retinal and ⅔ β-carotene.
 16. Process asclaimed in claim 14, characterized in that, the total amount of retinaland β-carotene is composed of ⅓ retinal and ⅔ β-carotene.
 17. Use asclaimed in claim 13, characterized in that, the dose of β-carotene is 10mg/day to 25 mg/day.
 18. Process as claimed in claim 14, characterizedin that, the dose of β-carotene is 10 mg/day to 25 mg/day, 19.Combination of ascorbic acid, tocopherol, retinol and β-carotenecontaining ascorbic acid in a free form and tocopherol and retinol infree form or/and in the form of pharmaceutically acceptable estersthereof and β-carotene in a free form in a mass ratio relative to oneanther of 1.5-2.5:0.3-0.8:0.0.028-0.033 based on asorbic acid,α-tocopherol as an acetate and retinol as an acetate together withβ-carotene for use as an agent to improve the tolerability of thechemotherapy or/and radiation therapy of malignant tumors.